Vision Screening Results Form

 

 

 

 

 

 

Vision   S creening   R esults   F orm  

 

Student’s Name: ___________________________________________ Sex: __________

School: __________________________________________ Grade: ______ Student Number: ____________________

Screening Date: ____________________

Glasses / Contacts: Yes / No

Visual   S creening   R esults   U sing   T hreshold   C harts  

 

                          C ircle   O verall   R esults                                                                                                                         R ight   E ye  

 

Left   E ye  

 

                          P ASS                                       * REFER                                                                                                                         2 0/______                                                         2 0/______  

 

*Student   u nable   t o   c orrectly   i dentify   3   o ut   o f   5   s ymbols/letters   o n   l ine   2 0/32   i n   e ither   e ye  

 

Comments:   _ ___________________________________________________________________________________________________________________          

 

 

 

Your   c hild   d id   n ot   p ass   t he   V ision   S creening   T est   d one   a t   s chool.   T his   s creening   w as   d one   t o   d etect   p ossible   v ision  

or   e ye   p roblems   t hat   c ould   a ffect   y our   c hild’s   l earning.   I t   i s   i mportant   t hat   y ou   c ontact   a   p hysician   o r   e ye   c are  

professional   a s   s oon   a s   p ossible   t o   f ollow-­‐up   o n   t hese   f indings.   I f   y ou   n eed   a ny   h elp   o r   f inancial   a ssistance   t o  

do   t his,   p lease   c ontact   t he   s chool.  

 

We   n eed   t o   k now   t hat   y ou   r eceived   t his   n otice   a nd   f ollow-­‐up.   P lease   c omplete   t his   p ortion   a nd   r eturn   i t   t o   t he  

school   a s   s oon   a s   p ossible.    

 

Child   w as   e xamined   b y   ( doctor)____________________________________________   o n   ( date)   _ ___________________________  

 

Check   o ne:  

 

_______   N o   f urther   t reatment   w as   r ecommended        

_______   T reatment   w as   r ecommended   f or   t he   f ollowing   c ondition   _ _________________________________________  

_______   M y   c hild   r eceived   g lasses  

_______   I   d o   n ot   r ead   E nglish.   N ative   L anguage   _ ________________________________  

 

Parent/Guardian   S ignature_____________________________________________________     D ate   _ __________________________  

2/11/13